6. Diabetes

Question 1

The pancreas is damaged, and the beta cells don’t produce enough insulin. (Immunologic etiology)

Answer 1

Type 1 diabetes mellitus

Question 2

The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time, beta cells fail.

Answer 2

Type 2 diabetes mellitus

Question 3

can develop diabetic ketoacidosis (DKA).

Answer 3

Type 1 DM

(Metabolic gap acidosis associated with a pH

Question 4

often develop hyperosmolar hyperglycemic state (HHS)

Answer 4

Type 2 DM

Plasma glucose levels are usually >600 mg/dL.

Question 5

Both HHS and DKA are life-threatening conditions that require prompt management.

Answer 5

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Question 6

Physical findings of HHS

Answer 6

HHS is characterized by severe dehydration. A profound fluid deficit is usually present, in excess of 9 L on average in adults. Serum osmolality usually exceeds 320 mOsm/kg. Fluid replacement is a key component of treatment.

Question 7

Precipitants of HHS

Answer 7

Infections, like pneumonia and urinary tract infections, accompanied by a decreased fluid intake are the most common underlying causes of HHS. Other acute conditions like stroke, MI or pulmonary embolism may also precipitate HHS.

Question 8

In the absence of risk factors, screening for DM should begin at what age?

Answer 8

45

testing should be repeated at least at three-year intervals

Question 9

Diagnostic Criteria for Diabetes Mellitus

Answer 9

1. A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia like polyuria or unexplained weight loss, or hyperglycemic crisis.
2. A fasting plasma glucose of greater than or equal to 126 mg/dL.
3. A hemoglobin A1C greater than or equal to 6.5%.

Question 10

physical exam in DM

Answer 10

Examine thyroid for enlargement or masses because thyroid disease can lead to diabetes and hyperlipidemia. Examine eyes for retinopathy, heart and lungs, and check feet for sores, ulcers and sensation

Question 11

In severe, non-proliferative retinopathy, look for the following findings on fundoscopic exam:

Answer 11

Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.

Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages.

Microaneurysms are more punctate dark lesions that indicate vascular dilatation.

Question 12

Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.

Answer 12

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Question 13

testing for loss of protective sensation

Answer 13

Sensory testing with a 10-gram monofilament PLUS any one of the following:

vibration using 128-Hz tuning fork
pinprick sensation
ankle reflexes (Achilles necessary, but patellar not needed)

Question 14

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus

Answer 14

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Question 15

High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated

Answer 15

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Question 16

Lowering patients A1C to

Answer 16

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Question 17

ADA/EASD Consensus Algorithm for the Management of Type 2 Diabetes

Answer 17

Tier 1 - well validated approach

Step 1: Diagnosis = HbA1C > 6.5% = Lifestyle changes plus Metformin

Step 2: Assessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + Add either a sulfonylurea (Glyburide, Glipizide (both second generation) or Glimepiride (third generation)) or basal insulin (Insulin Glargine (Lantus) or Insulin Detemir (Levemir) on intermediate-acting insulin (NPH).

Step 3: Reassessment. (If HbA1C > 8) = Continue lifestyle changes and Metformin + add basal insulin or (if already added) intensify insulin regimen. Consider discontinuing sulfonylurea to avoid hypoglycemia.

Question 18

It is part of the natural progression of type 2 diabetes that beta-cell function declines, and patients need additional medication…insulin…to lower A1c

Answer 18

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Question 19

Vaccines Recommended for Patients with Diabetes

Answer 19

Influenza vaccine should be provided to patients with diabetes annually.

Pneumococcal polysaccharide vaccine should be provided to all patients with diabetes over 2 years of age

Hepatitis B vaccine should be administered to all unvaccinated adults with diabetes, HIV, other immunocompromising conditions, or liver disease.

Question 20

Optimal range for blood glucose

Answer 20

fasting blood glucose should be 80 -120 mg/dl

postprandial blood glucose between 1-2 hours after a meal should be

Question 21

Conditions that contribute to hyperglycemia

Answer 21

Overeating, missing doses of medication, dehydration, infection and illness, and stress